Hospitalists & Handoffs

In the nearly 10 years since the word “hospitalist” entered our consciousness, it has been inspiring to witness the dramatic growth in the specialty and, accompanying it, the growth in the membership of SHM.1 Over this same period, the healthcare system has made progress toward ensuring that it provides the safest, highest quality healthcare possible.

In my mind, the two phenomena are related. SHM itself and—more generally—the hospitalist field have played a vital role in promoting the use of evidence-based care, improved teamwork, and health information technology. Each of these efforts has made a significant difference in the care patients receive in hospitals. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. Both organizations are working to create positive change that will improve the health and healthcare of all patients.

As their numbers continue to grow, hospitalists are becoming integral members of the inpatient care team at many hospitals.

According to a recent survey conducted by SHM, a hospitalist averaged more than 2,300 inpatient encounters in 2005—a 7% increase over 2004.2 Today, hospital medicine groups practice not only in large metropolitan areas, but also in rural regions where one in three groups began operation during 2005.

In addition to their inpatient care responsibilities, the 15,000 hospitalists who practice today in the United States and Canada serve in key physician leadership roles that directly influence quality improvement and patient safety. Most hospitalists—86%—participate in quality improvement. More than half are involved in implementing information technology (54%) and teaching house staff (51%), and more than one-third—35%—are responsible for their organization’s rapid response team. The SHM survey found that nearly all hospital medicine groups provide round-the-clock patient care at their hospitals.

In this article I will emphasize two key areas relevant to improving patient safety for hospitalized patients: patient handoffs and communication.

Responsibility for Patient Handoffs

Hospitalists’ clinical and leadership roles are significant responsibilities for patient safety, including the critical period known as patient handoff or sign-out.

Patient handoffs refer to the interaction, communication, and planning required to achieve a seamless transition from one clinician to the next.3 When executed in a timely and thorough manner, patient handoffs can reduce the likelihood of medical errors and misinformation, prevent lost or missing clinical information, and maintain a high level of medical care.

Given today’s short hospital stays and the complex medical nature of the care necessary for many patients, timely and effective handoffs demand that hospitalists develop skills that extend beyond superior clinical care. They include:

Communicating in an effective and efficient manner during patient sign-out;

Demonstrating the use of “read-back” skills when communicating tasks;

Developing oral and written patient summaries, including characteristics of the patient, provider, and time of the sign-out;

Evaluating all medications for indication, dosing, and planned duration at the time of sign-out; and

Anticipating what may go wrong with a patient after a transition in care occurs and clearly communicating this concern to the receiving clinician.

A Fumbled Handoff: A Case Study

A breakdown in communications—notably an error of omission in the patient handoff—contributed to a poor outcome for an elderly patient who was admitted to the hospital for an elective sigmoid resection.

The case, which was published in the AHRQ’s “Morbidity and Mortality Rounds on the Web” (developed by hospital medicine expert Robert Wachter, MD, and his team under contract to our agency), illustrates some of the challenges that face all clinicians in effectively transferring patient information and care responsibilities.4 It also underscores the need for close involvement by hospitalists in improving quality, teaching and supervising house staff, and implementing information systems.

According to the case study, a 73-year-old female patient with a history of hypertension, non-insulin dependent diabetes, and chronic renal insufficiency became tachycardic two days after surgery, despite receiving a low-dose beta-blocker. The same day, she informed her nurse that she had developed pain in her left leg.

Assuming the pain was related to the pre-operative epidural, the nurse contacted the anesthesia service, which responded by decreasing the epidural rate; the primary surgical team was not called. Late on the third day after surgery, the cross-covering intern was contacted about the patient’s left leg pain. No information about the intern’s findings was relayed to the primary team the following day.

On the fourth day, the patient complained to the nurse about mild chest discomfort, resulting in attention within 20 minutes by house staff and from the attending physician several hours later. The patient’s exam was unremarkable and a work-up was initiated.

Within an hour of the attending’s visit, the patient’s blood pressure dropped to 70/40, followed by a pulseless electrical activity arrest. The patient could not be resuscitated. A post-mortem examination revealed a pulmonary embolism.

Handoffs in an Era of Work-Hour Restrictions

Missing information about pain in the patient’s leg and a breakdown in communication between physicians contributed to the patient’s poor outcome. In this case, the breakdown may also have been influenced by the intern’s involvement on the third day. Like all medical residents this intern is subject to duty-hour restrictions.

Work-hour limits for all residents training in U.S. hospitals took effect in July 2003. Under these standards, created by the Accreditation Council for Graduate Medical Education (ACGME), residents are limited to a maximum of 30 consecutive work hours—known as the 30-hour rule, which includes time used for sign-out, teaching, and continuity of care. They are also prohibited from working more than 80 hours per week.

Despite the clear safety benefit of preventing fatigue-related mistakes, work-hour mandates have increased the number of patient handoffs and the potential for communication breakdowns.5 A survey of interns conducted at the hospital where this case study occurred identified a higher volume of sign-outs and the resulting potential for harm to patients as main concerns with the work-hour restrictions.6

Concerns about the quality and continuity of care that hospital patients receive are evident even among those medical residents whose work hours were restricted before the ACGME requirements took effect. (In New York state residents’ work hours have been restricted since 1998.)

A 2006 study of surgical residents at New York’s Beth Israel Hospital found that most believed that the quality of care patients received was either unchanged (63%) or worse (26%) since the work-hour restrictions took effect.7 Possible reasons for this perception include unresolved issues with continuity of care, miscommunication, and cross-coverage availability. The study concluded that interventions that target intern sign-out coverage constraints will be important for future efforts to improve the quality of care for hospital patients.

Written sign-outs appear to overcome some of the human errors that inevitably result from verbal patient summaries, such as disruptions and forgetfulness. Recent findings have, however, identified significant shortcomings in the quality and timeliness of written reports.

Critical information, such as code status and allergies, was missing in 80% of written sign-outs in one recent study.8 And in a 2006 study of the quality of discharge summaries, only 19% of hospital physicians with an outpatient practice reported being satisfied with the timeliness of discharge summaries. Only a third reported being satisfied with their quality of information. Most troubling, 41% believed that at least one of their patients hospitalized in the previous six months had experienced a preventable adverse event related to poor transfer of information at discharge.9

Use Redundancy and Simulation to Improve Safety

Given the clear challenges of providing quality and continuity of care in the inpatient setting, hospitalists are well positioned to identify strategies for safe and effective patient handoffs and advocate for a systems approach to their implementation.

Safety strategies that have been employed by industries outside of healthcare can provide a useful starting point. So-called “highly reliable” organizations use a variety of approaches to reduce the incidence of errors that occur during transitions in work staff. A recent review of transition methods used by NASA’s Johnson Space Center (Houston), Canadian nuclear power plants, and an ambulance dispatch center—organizations where lapses in transitions also have serious consequences—found that these entities used up to 21 handoff strategies.10 Techniques included verbal, face-to-face, and interactive questioning coordinated with written summaries just before a shift change.

Increasing redundancy is another technique used by highly reliable organizations to reduce the likelihood of missed, incomplete, or misinterpreted information. To create redundancy in clinical care, a physician would include more information at the outset of a procedure or medication order than is now typically provided. This additional information is then repeated and validated by other members of the care team throughout the process, reducing the likelihood of misinterpretation of an instruction or action based on incomplete information.

For example, if a physician always includes both the drug name and the condition for which it is prescribed, a medication order for “Celebrex, seizures,” instead of “Cerebyx, seizures,” would immediately indicate a mistake had occurred in ordering a pain medication instead of an anti-convulsant.11 Research has shown that increasing the amount of information about a medication order reduces the range of potentially valid clinical decisions.

Whether a hospital relies on verbal communication, written communication, computer-based communication, or a combination of all three, redundancy can be built into its sign-out processes. As PDAs become more widely used, structured sign-outs should incorporate redundancy into patient-specific checklists to include information on clinical status, recent and pending tests and study results, and similar, pertinent information.

AHRQ has recently funded research on simulation training projects that seek to:

Reduce communication errors during patient handoffs in the emergency department by implementing a patient-specific checklist based on an electronic medical record and by testing the effect of companion simulation-based training; and

Evaluate and improve safe communication and coordination between anesthesia providers and nurses during care transitions and during hand-offs between the operating room and the post-anesthesia care unit.12

The 24/7 role of hospital physicians brings unique experiences and insights to the challenges of patient safety that can test the feasibility of systems to reduce errors associated with care transitions. As their numbers and leadership roles expand, hospitalists are poised to make significant contributions to improving patient safety and outcomes.

We at AHRQ look forward to assisting hospitalists in making these contributions and to achieving these goals together. We also look forward to continuing our relationship with SHM and the hospitalist community as a whole. TH

Dr. Clancy is the director of the Agency for Healthcare Research and Quality.

Society of Hospital Medicine. The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine. J Hosp Med. 2006;1;S1. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.72/pdf. Last accessed January 17, 2007.

Vidyarthi A [commentary]. Agency for Healthcare Research and Quality Web M&M: Morbidity and Mortality Rounds on the Web. Fumbled handoff. March 2004. Available at: www.webmm.ahrq.gov/case.aspx?caseID=55. Last accessed January 17, 2007.